Dysmenorrhoea: When can we stop talking about it?

Brenda Lau, 16 Mar 2018

Are women just over-exaggerating about dysmenorrhoea being labelled "almost as bad as having heart-attack", or is there some truth to it?

Teenage girls and women all around the world usually suffer through menstrual cramps every month. While the severity of it can vary, intense menstrual pain is no laughing matter. Yet, women all around the globe have always been told that their cramps are not that bad or that the pain is just all in their heads – usually by cisgender men, of course.

Therefore, it comes as no surprise when women on Twitter reacted virally to John Guillebaud, Emeritus Professor of Family Planning and Reproductive Health at University College London, saying that some of his patients have likened their period pain experience as “almost as bad as having a heart-attack”.

The quote provided the crux to two articles: on Marie Claire’s website on 27 February, that was originally published on Elle UK. Both articles sourced the quote from an article in Quartz, that examined the lack of research surrounding severe menstrual cramps and other causes of dysmenorrhea, two years ago.

But are these just over-exaggerated reactions or is there some truth to it?

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A real matter, overlooked too frequently

Let us begin by putting out the fact that dysmenorrhoea is real.

“[The explanation] is not over-exaggerated, it is a well-recorded condition,” says Dr Raman Subramaniam, a consultant obstetrician and gynaecologist at Pantai Bangsar, Malaysia. “If you look up the literature, this has been recorded for a long time. About 10% of women faint, and about 20% can’t even go to work.”

Likewise, Dr Tang Boon Nee, a consultant obstetrician and gynaecologist at Ramsay Sime Darby Medical Centre, Malaysia, says, “Dysmenorrhoea, is one of the experiences my patients talk about a lot. It is debilitating, and unlike a heart attack, lasts for days; in waves.”

“Perhaps one more point to make, would be that dysmenorrhoea is repeated every month unlike a heart attack, which is usually one off!” she adds.

Dr Raman Subramaniam say that women do not ovulate every month. “Out of 12 months, a normal woman ovulates only 10 months, so if they don’t ovulate, they don’t get pain.” Photo credit: Utusan online

The causes of dysmenorrhoea vary and depends on the type – whether it is primary or secondary.

“The one that causes trouble is primary dysmenorrhoea, which is related to ovulation and progesterone, and that in turns releases prostaglandin,” Dr Raman details, “Prostaglandin causes the uterus to contract, leading to the extreme pain.”

On the other hand, secondary dysmenorrhoea is due to other causes such as ovarian cysts, endometriosis, fibroids, etc.

“They don’t cause the extreme pain like primary dysmenorrhoea, but instead are chronic. These types of pain can start 48 to 72 hours before a period, last for the first two or three days, before settling,” Dr Raman explains.

While the causes of secondary dysmenorrhoea can be pinpointed, “no one is really sure why primary dysmenorrhoea happens,” states Dr Tang. However, as anti-inflammatory medicines seem to work, it is postulated that inflammatory agents or factors play a role.

“Some girls have more severe inflammation around the uterus during periods, and these girls may tend to have more gynaecological problems later – such as cysts or endometriosis,” says Dr Tang, who based it on her experience. She suggested for research to be done, to confirm the association, as she observed that “girls who develop severe endometriosis later in life tend to experience more dysmenorrhoea when young.”

Start believing: From medicine to research

Perhaps it is this vagueness that makes the issue seem so small. Or perhaps, because a woman’s pain is taken less seriously than a man’s that dysmenorrhoea is just “all in their heads”. Or even perhaps, because medicine has been male-dominated for so long, that even researchers attempting to study menstrual pain have difficulty securing funding.

Kathy Lustyk is now dean of the College of Arts and Sciences on Embry-Riddle Aeronautical University’s Prescott Arizona campus. She holds a PhD degree in physiological psychology with a minor in endocrinology. Photo credit: The Embry-Riddle Newsroom

For example, Kathleen Lustyk of the University of Washington told ResearchGate in 2016, that some of her grant reviews were rejected as the reviewers did not believe in pre-menstrual syndromes. Quoting the reviewers, Lustyk was told PMS is “merely a product of our society or culture that has painted a natural process in a negative light and that, given its monthly predictability, leads to suffering through anticipation.”

“I suspect that this is a fancy way of saying it’s really just in a woman’s head,” Lustyk says.

To this, Dr Raman reiterates, that the problem is “not new and it is a very severe pain.”

“We have worked out the mechanism and the pathophysiology, and if the doctors don’t believe it, then they don’t understand the mechanism and what the cause is,” he laughs.

As for the pain, “it is mainly due to the pressure of the uterus contracting – which is very high,” Dr Raman says.

Citing a research from Sweden, whereby a catheter was inserted into the uterus of women who experienced dysmenorrhoea, Dr Raman elaborates that the pressure measured was recorded as almost that of the second stage of labour – approximately 70mmHg.

So yes, the pain can be very real. But why does the severity of dysmenorrhoea differ between women?

Listen to all patients and start making a change

Dr Tang Boon Nee, a consultant obstetrician and gynaecologist at the Ramsay Sime Darby Medical Centre, says regular exercise and reducing stress can help with dysmenorrhoea.

“The experience of dysmenorrhoea is variable due to multiple factors such as pain threshold, upbringing and cultural differences,” Dr Tang says.

“What is pain to me, might not be pain to me. How do you measure pain?” Dr Raman asks. “There is no instrument. It is a visual-analogue scale.”

“Pain is relative, that is a simple answer,” he concludes.

However, Dr Tang says, “Pain is pain. So, all girls who report painful periods should be given attention. The ‘traditional’ idea that ‘Periods are meant to be painful, so just bear it’ should not be supported at all.”

Dr Raman echoes her thoughts, saying, “There are thousands of doctors in the Klang Valley, if they [patients] see a doctor that doesn’t listen to them, change the doctor!”

Cyclical oral contraceptives are recommended as long-term measures to relieve the pain of dysmenorrhoea.

“The pain usually improves after childbearing and other things can be done, for example taking the contraceptive,” Dr Raman assures.

Explaining the pathophysiology, he states that the contraceptive pill halts ovulation, and in turn resolves the pain. He also states that dysmenorrhoea ends by early 20s and is rare to continue beyond that.

“Exercising regularly and reducing stress seems to help as well, in the short-term,” Dr Tang elaborates. Like Dr Raman, Dr Tang also recommends cyclical oral contraceptives as long-term measures.

“I’m in shock, we already know all these. And yet, nothing has changed since then, except the addition of treatment options,” Dr Raman says exasperatedly.

And, rightfully so.

Despite gynaecology being a field made up of 85% women, the after effects of it being previously cis-male-dominated are still being seen. Experts have been brushing off period pain for years, decades, and even centuries, deeply ingraining the idea that period pain is a small matter.

At the recent Malaysian Community Pharmacy Business Forum (MyCPBF), a discussion forum was held on the subject of “Transcending Primary Healthcare Services: The Future of Specialized Pharmacy Services and Pharmacy Specialization”.